Provider Demographics
NPI:1245222447
Name:KILLEEN, ROBERTA MARIE (MD)
Entity Type:Individual
Prefix:
First Name:ROBERTA
Middle Name:MARIE
Last Name:KILLEEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2520 US HIGHWAY 19
Mailing Address - Street 2:
Mailing Address - City:HOLIDAY
Mailing Address - State:FL
Mailing Address - Zip Code:34691-3846
Mailing Address - Country:US
Mailing Address - Phone:727-934-6905
Mailing Address - Fax:727-934-4045
Practice Address - Street 1:2520 US HIGHWAY 19
Practice Address - Street 2:
Practice Address - City:HOLIDAY
Practice Address - State:FL
Practice Address - Zip Code:34691-3846
Practice Address - Country:US
Practice Address - Phone:727-934-6905
Practice Address - Fax:727-934-4045
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-16
Last Update Date:2011-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME58665207ZP0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL052961300Medicaid
E88641Medicare UPIN
FL11844Medicare ID - Type Unspecified